Failure to Prime Insulin Pen and Timely Administer Insulin
Penalty
Summary
A deficiency was identified when a nurse failed to prime a new insulin pen prior to administering insulin to a resident diagnosed with type 2 diabetes mellitus, hypertension, and a history of transient ischemic attack. The nurse admitted to not priming the pen before injection, which is contrary to both facility policy and standard practice, as confirmed by the Director of Nursing. The facility's policy requires insulin pens to be primed before use to ensure the correct dose is delivered and to avoid air in the reservoir. The resident involved was cognitively intact, as indicated by a perfect BIMS score. Additionally, the facility failed to administer insulin as ordered for the same resident on multiple occasions. Medication administration records showed that the resident's scheduled morning insulin doses were given several hours late on at least five separate dates. Interviews with nursing staff and the DON confirmed that staff are educated to administer medications within one hour before or after the scheduled time, but the audit revealed repeated late administrations outside this window.